What is the best cut-off point for screening gestational diabetes in Turkish women?
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A. KÖŞÜŞ, N. KÖŞÜŞ, N. TURHAN
Turk J Med Sci
2012; 42 (3): 523-531
© TÜBİTAK
E-mail: medsci@tubitak.gov.tr
Original Article doi:10.3906/sag-1102-1368
What is the best cut-off point for screening gestational diabetes
in Turkish women?
Aydın KÖŞÜŞ, Nermin KÖŞÜŞ, Nilgün TURHAN
Aim: To find an optimal threshold level with higher sensitivity and specificity for screening of gestational diabetes
mellitus (GDM) in Turkish pregnant women.
Materials and methods: This was a retrospective study. Screening for GDM was performed in all pregnant women
between 24 and 28 weeks of gestation using the 1 h 50 g glucose challenge test (GCT) with a subsequent 3 h 100 g oral
glucose tolerance test (OGTT) for confirmation if screened positive. The glucose values obtained were analyzed by both
the Carpenter and Coustan (C&C criteria) and National Diabetes Data Group (NDDG) criteria.
Results: There were 808 women meeting the study inclusion criteria. There were 66 (8.1%) women diagnosed with
GDM using the C&C criteria and 45 (5.7%) using the NDDG criteria. The best cut-off point for GCT was 132 mg/dL for
detecting GDM. No diabetes was found below the glucose level of 130 mg/dL.
Conclusion: GCT is suitable for screening of Turkish women, but place of residence as well as race must be taken into
consideration to establish the best cut-off level of GCT, since ethnic and environmental factors may contribute to the
occurrence of GDM.
Key words: Gestational diabetes, glucose challenge test, glucose tolerance test, cut-off
Türk kadınlarında gestasyonel diyabetin taranmasında en uygun kesme noktası
nedir?
Amaç: Gebe Türk kadınlarında gestasyonel diyabetin (GDM) taranmasında en yüksek sensitivite ve spesifisiteye sahip
olan optimal kesme noktasını bulmaktır.
Yöntem ve gereç: Bu çalışma retrospektif olarak yapılmıştır. Tüm gebe kadınlara 24-28 haftalar arasında 1 saatlik 50
gr glukoz deneme testi (GCT), bu testin pozitifliği durumunda da 3 saatlik 100 gr oral glukoz tolerans testi (OGTT)
yapıldı. Elde edilen glukoz değerleri hem Carpenter ve Coustan (C&C) hem de National Diabetes Data Group (NDDG)
kriterlerine göre incelendi.
Bulgular: Çalışma kriterlerine uyan 808 kadın çalışmaya alındı. C&C kriterlerine göre 66 (% 8,1) kadına GDM tanısı
konulurken, NDDG kriterlerine göre 45 (% 5,7) kadın bu tanıyı aldı. GDM tesbitinde en uygun kesme noktası GCT için
132 mg/dL olarak tesbit edildi. GCT sonucu 130 mg/dL altında olan hiçbir hastada GDM izlenmedi.
Sonuç: GCT Türk kadınlarının taranması için uygun bir testtir. Ancak yerleşim yeri ve ırk faktörü de GCT için kesme
noktasının belirlenmesinde dikkate alınmalıdır. Çünkü etnik ve çevresel faktörlerin gestasyonel diyabet gelişimine
katkısı olabilir.
Anahtar sözcükler: Gestasyonel diyabet, glukoz yükleme testi, glukoz tolerans testi, kesme noktası
Received: 07.02.2011 – Accepted: 15.04.2011
Department of Obstetrics & Gynecology, Faculty of Medicine, Fatih University, Ankara - TURKEY
Correspondence: Nermin KÖŞÜŞ, Ostim Mah. 1290. Sokak, Nevbahar Konutları G8 blok No: 43, Yenimahalle, Ankara - TURKEY
E-mail: nerminkosus@gmail.com
523Screening for gestational diabetes in Turkish women
Introduction unnecessary intervention. In this study we tried to
Gestational diabetes mellitus (GDM) is defined as find an optimal threshold level with higher sensitivity
any degree of glucose intolerance with onset or first and specificity for screening of GDM in Turkish
recognition during pregnancy (1,2). It affects 1.2% to pregnant women.
14.3% of the pregnant population (1,2). Prevalence
rates of GDM varies widely by ethnicity (3,4); Materials and methods
Asians have the highest reported prevalence rates
(4,5). Considering GDM consequences of increased This retrospective study of diagnostic accuracy was
perinatal and maternal morbidity and mortality, in conducted between January 2008 and December
addition to long-term complications, its accurate 2009 in Fatih University, Faculty of Medicine,
identification and treatment is very important (6,7). Ankara. Women screened for GDM and who had
given birth at Fatih University were enrolled in the
The American College of Obstetricians and study. All relevant data including demographic
Gynecologists (ACOG) and the American Diabetes information, and GCT and OGTT results were
Association (ADA) have both recommended that all collected for further analysis. Patients with potential
pregnant women should be screened for GDM (8,9). diabetic pregnancy and any systemic disease were
While the optimal method of screening remains excluded from the study. Criteria for potential
controversial, the 50 g 1 h glucose challenge test diabetic pregnancy were one or more of the following:
(GCT) is performed most commonly in the world. previous history of GDM, including familial history;
This is often followed by a 100 g 3 h oral glucose previous fetal weight > 4000 g, previous infants with
tolerance test (OGTT) for confirmation, if screened congenital anomalies; previous unexplained fetal loss;
positive. hypertension; glucosuria by urine strip; and previous
The threshold for a positive GCT necessitating history of diabetic complications, polyhydramnios,
further diagnostic testing remains controversial (8- multi-fetal pregnancies, and delivery prior to 24
10). In the previous studies, authors recommended completed weeks of gestation.
the use of a GCT cut-off level of 130-140 mg/dL Screening for GDM was performed in all pregnant
for screening of GDM between 24 and 28 weeks of women between 24 and 28 weeks of gestation using
gestation (11,12). However, in later studies, most of the 1 h 50 g GCT in accordance with protocols
the cut-off values were different from those in the recommended by the ADA and the ACOG with
previous reports (13,14). These findings may have a subsequent 3 h 100 g OGTT for confirmation
been due to the differences in race and nutrition of if screened positive. A positive result was defined
the population. as plasma glucose of 125 mg/dL or greater. The
Both the ADA and ACOG have stated that a threshold was taken as 125 mg/dL in order not to
glucose threshold value of ≥140 mg/dL identifies 80% miss GDM cases that can be seen with the lower GCT
of women with GDM, and the diagnostic accuracy is results. The glucose values obtained were analyzed by
further increased to 90% using a cut-off of 130 mg/ both the Carpenter and Coustan (C&C criteria) and
dL. No definitive screening threshold was adopted National Diabetes Data Group (NDDG) criteria for
by the ACOG, who stated that “either threshold is the diagnosis of GDM and IGT (15,16).
acceptable” (1,2). An abnormal 3 h OGTT is defined as 2 or more
While a higher threshold gives better specificity plasma glucose values that meet or exceed the
and lowers the likelihood of a false-positive test standards of C&C criteria (fasting ≥ 95, l h ≥ 180,
result, the disadvantage is that a number of women 2 h ≥ 155, and 3 h ≥ 140 mg/dL) and the NDDG
who may have gestational diabetes will remain (fasting ≥ 105, 1 h ≥ 190, 2 h ≥ 165, and 3h ≥ 145
undiagnosed and untreated. In contrast, a lower mg/dL). Fasting plasma glucose (FPG) ≥ 140 mg/dL
threshold yields a higher sensitivity, but more women was considered as showing diabetes and GCT was
will undergo unnecessary diagnostic testing, which omitted. Plasma glucose ≥ 200 mg/dL after GCT were
can be expensive, time-consuming, and leads to also accepted as showing diabetes and 3 h OGTT was
524A. KÖŞÜŞ, N. KÖŞÜŞ, N. TURHAN
not performed. Treatment was based on the diagnosis exact test were used for comparison of categorical
made according to the C&C criteria. Plasma glucose variables. Receiver–operating characteristics (ROC)
was determined from a peripheral venous sample by curve analysis was performed to find the optimal
the hexokinase method (COBAS Integra 800, Roche, cut-off point. Sensitivity; specificity; the area under
Germany). the curve (AUC), which reflects the probability of
Firstly patients with GDM and IGT were seen correctly identifying patients; positive predictive
by a dietician and received a dietary evaluation and value (PPV); and negative predictive value (NPV)
diet therapy to achieve normoglycemia. Diet therapy were calculated. Two-tailed P < 0.05 was considered
continued if fasting blood sugar (FBS) < 105 mg/dL, statistically significant.
and 2 h postprandial < 140 mg/dL, with home blood
sugar monitoring continued once daily. In women Results
with glucose values > 200 mg/dL on initial OGTT and
those who recorded FBS > 105 and 2 h postprandial There were 808 women meeting the study inclusion
glucose > 140 for at least 2-3 values while on a dietary criteria and available for analysis. The characteristics
regimen, insulin therapy was commenced. of the patients in this study were as follows [expressed
as the median (IQR)]: maternal age was 28 (7)
The statistical analyses were carried out using years, gravida 2 (2), parity 1 (2), BMI 26 (5), birth
SPSS 15.0. Following the entering of patient data weight 3300 (300) g, GCT 157.50 (26). Demographic
into the computer, all the necessary diagnostic characteristics according to GCT results are shown
checks and corrections were performed. Normal in Table 1. Maternal characteristics associated with
distribution of measurement values as a convenience higher GCT categories included age ≥ 35 and
was examined graphically and with the Shapiro-Wilk multiparity (P < 0.001, P = 0.002).
test. In presenting descriptive statistics, numbers
and percentages were used for categorical variables, There were 66 (8.1%) women diagnosed with
and median (interquartile range [IQR]) and mean GDM using the ADA criteria and 45 (5.7%) using the
± SD values were used for the data. The groups, NDDG criteria during the study period. No diabetes
which were formed according to level of glucose was found below the glucose level of 130 mg/dL.
intolerance, were compared to each other by Kruskal If 132 mg/dL was taken as the cut-off point only 2
Wallis test and Bonferroni corrected Mann Whitney women with GDM were seen below this level.
test. Spearman correlation analysis was used for Of the 12 women with GDM, 4 needed insulin
evaluation of the relationship between demographic treatment. The GCT results of all patients requiring
variables and GCT results. Chi-square and Fisher’s insulin treatment were over 200 mg/dL. Table 2
Table 1. Demographic characteristics and GCT results of groups (median (IQR)).
Normal GCT FP-GCT IGT GDM P value
Age (year) 28.0 (7.0) 28.5 (7.0) 29.0 (7.0) 28.5 (9.0) 0.612
Gravidity (n) 2.0 (2.0) 2.0 (2.0) 2.0 (3.0) 2.0 (2.0) 0.858
Parity (n) 1.0 (1.0) 1.0 (2.0) 1.0 (2.0) 1.0 (2.0) 0.893
G. age (week) 26.0 (3.0) 26.0 (3.0) 27.0 (3.0) 27.0 (3.0) 0.269
BMI 26.0 (5.0) 25.0 (4.0) 26.0 (5.0) 26.0 (4.0) 0.624
GCT 112.0 (72.0) 143.5 (22.0) 160.0 (21.0) 175.0 (48.0)Screening for gestational diabetes in Turkish women
Table 2. Sensitivity and specificity of various cutoff values of GCT.
GDM according to GDM according to
Cut-off Sensitivity Specificity PPV NPV
C&C NDDG
(mg/dL)
n % n % (%) (%) (%) (%)
130 66 100,0 45 100,0 100,0 68,5 21,3 100
132 64 97,0 45 100,0 97,4 70,5 22,6 99,6
140 58 87,9 43 95,6 84,8 77,8 25,0 98,6
150 48 72,7 36 80,0 72,7 86,0 30,4 97,2
160 39 59,1 30 66,7 57,6 91,9 37,1 96,2
170 28 42,4 20 44,4 42,4 95,1 43,8 94,9
180 22 33,3 14 31,1 33,3 97,3 52,4 94,3
PPV: Positive predictive value
NPV: Negative predictive value
shows the sensitivity and specificity of various cut-off presenting sensitivity and specificity
values of GCT. The probability of GDM in patients
with different GCT results is shown in Table 3. The 1.0
ROC curve identified the GCT result above 132 mg/
dL as useful for detecting GDM (Figure). At this 0.8
cut-off value, the sensitivity, specificity, PPV, and
NPV of GCT were 97.0%, 70.5%, 22.6%, and 99.6%,
Sensitivity
respectively [AUC = 0.903 (95% CI: 0.877-0.930; P 0.6
< 0.001)]. If 132 was taken as cut-off point to detect
IGT together with GDM, sensitivity and specificity 0.4
would be 99.1% and 74.0%, respectively (AUC =
0.921, 95% CI: 0.901-0.941; P < 0.001) (Figure).
0.2
Table 3. The probability of GDM in patients with different GCT 0.0
results. 0.0 0.2 0.4 0.6 0.8 1.0
1 - Specificity
Figure. ROC curve presenting sensitivity and specificity.
Cut-off value GDM (C&C) GDM (NDDG)
(mg/dL) n (%) n (%)
Relation between GCT results and demographic
130 66 (21.3) 45 (14.5) variables were examined by Spearman correlation
132 64 (22.6) 45 (15.9) analysis. A weak positive correlation was found
between GCT and maternal age, gravida, parity, and
140 58 (25.0) 43 (18.5) birth weight. There was a positive correlation between
150 48 (30.4) 36 (22.8) GCT value and 100 g OGTT 0, 1, and 2 h glucose
levels. The relationship between OGTT results and
160 39 (37.1) 30 (28.6)
demographic variables was also examined. A positive
170 28 (43.8) 20 (31.3) but weak correlation was found between 0, 1, and 2 h
glucose levels and maternal age and BMI. Results of
180 22 (52.4) 14 (33.3)
the correlation analysis are shown in Table 4.
526Table 4. Correlation analysis between GCT results and demographic variables.
Birth Delivery
50 g GCT Age Gravida Parity BMI Gender 100 g 0 100 g 1 100 g 2 100 g 3
weight route
Rho 0.196(**) 0.161(**) 0.130(**) 0.101(*) 0.074 0.036 0.057 0.156(*) 0.150(*) 0.185(**) 0.117
50 g GCT
P valueScreening for gestational diabetes in Turkish women
Discussion still in use, while in the UK the WHO recommended
There is a general consensus that the prevalence of criteria following a 75 g OGTT are mostly used (26).
GDM is increasing globally. The prevalence of GDM A cut-off value between 130 and 140 mg/dL
is reported to be 1.2% to 14.3% in the literature (1,2). is commonly used for performing the diagnostic
Several studies have documented increasing trends OGTT in the clinical settings. To date, most studies
in the prevalence from 2% in 1982 (17) and 7.62% that have examined the screening threshold of GCT
in 1991 (18) to 16.55% in 2001 (19). A recent survey have focused on the sensitivity and specificity of
reported the prevalence of IGT in the age groups of different GCT thresholds. Several authors evaluated
20-29 years and 30-39 years as 12.2% and 15.3%, the sensitivity and specificity to determine the
respectively (20). The reasons for this increase and cut-off value in different populations (27,28). In
difference in prevalence rates in different populations most studies, the authors recommended the use of
are not known very well. GCT level at 130-140 mg/dL for GDM screening
Ethnicity is one cause. The prevalence of GDM in potential diabetic pregnancy between 24 and 28
varies widely with ethnicity (3,4). Asians have the weeks of gestation (11,12). However, in some studies
highest reported prevalence rates of GDM (4,5). considerably lower or higher thresholds for GCT
On the other hand, environmental factors also may are advised. For example, while Vitoratos et al. (13)
modify the condition. Asian immigrants in the recommended 126 mg/dL as the optimal threshold,
United Kingdom, the United States, and Canada Punthumapol et al. (29) recommended 177 mg/
were investigated in previous studies on racial dL and Tanir et al. (14) recommended 185 mg/dL.
variations in the incidence of GDM (21-23). As a These findings may be due to the differences in race
result, they found that environmental factors such as and nutrition of the populations. The sensitivity and
diet in Western countries may contribute to the high specificity of these cut-off values were 50%-78.33%
prevalence of GDM in Asian immigrants. Fujimoto and 65.75%-86.79%, respectively. The PPVs were
et al. (24) have shown that environmental factors 26.72%-33.96%. Although the PPVs were low, the
may play an important role in the development of NPVs were high, i.e. 92.73%-94.82%, that meant low
type 2 diabetes since the prevalence of type 2 diabetes false negative. Low PPVs were not a problem, because
is about 2-fold higher in Japanese Americans than in GCT is a screening test and must be confirmed by
native Japanese. Our own data show a prevalence of OGTT for exact diagnosis of GDM.
GDM of 8.1% if the diagnosis is based on the C&C Racial differences regarding the glucose screening
criteria. test findings have been demonstrated. Nahum and
Numerous screening and diagnostic procedures Huffaker (30) suggested race-specific criteria for GCT
such as glycosuria, random, and fasting plasma because of the heterogeneity of glucose intolerance
glucose to identify cases of GDM are employed between ethnic groups. In the study by Eslamian
worldwide (1,25), but there is no consensus as yet and Ramezani (31), for GCT, a sensitivity of 91.7%,
regarding the best screening method, with most specificity of 83.6%, PPV of 34.4%, and NPV of
centers using the ADA and the ACOG guidelines, 99.1% with a cut-off value of 135 mg/dL were found.
which recommend screening with the 50 g GCT, In the study of Miyakoshi et al., based on receiver
followed by a 3 h 100 g OGTT in women who screen operating characteristic curve (ROC), they identified
positive, while in the UK the 75 g load is favored, and a GCT finding above 140 mg/dL as the cut-off value
this is also recommended by the WHO. for detecting GDM, which showed a sensitivity and
Finally, even after the diagnostic test is conducted, specificity of 96% and 76%, respectively (12).
there is controversy regarding the diagnostic criteria. In Turkey, Korucuoglu et al. (32) suggested that
Because of perceived low sensitivities with the NDDG 50 g GCT as a diagnostic test is time-consuming,
criteria, the ADA recommended that the C&C uncomfortable, and expensive and can be omitted
criteria should replace the NDDG. However, both are up to a cut-off value of 147.5 mg/dL, especially for
528A. KÖŞÜŞ, N. KÖŞÜŞ, N. TURHAN
those patients with no risk factors. On the other and OGTT values. Therfore, it was stated that the
hand, a GCT value of 180 mg/dL or higher proves new IADPSG criteria were “not evidence-based” and
that a further diagnostic test is unnecessary as these need modification (35,36). Additional well-designed
patients are associated with unfavorable perinatal clinical studies are needed to determine the optimal
and fetal outcomes. They thought that this combined method and optimal threshold levels with higher
approach would improve maternal-fetal outcomes sensitivity and specificity for screening of GDM.
together with a decrease in unnecessary diagnostic In the present study, we used an ROC curve to
tests. find the best cut-off point. A cut-off value of 132 mg/
Recently, the Hyperglycemia and Adverse dL yielded a sensitivity of 97.4% and a specificity of
Pregnancy Outcomes (HAPO) study (33), which 70.5% for GDM. The proportion of gravidas exceeding
was a large-scale multinational epidemiologic study 132 mg/dL was found to be 35% of all subjects, and
including 25,000 pregnant women, demonstrated 22.6% of women with a positive screening test were
that risk of adverse maternal, fetal, and neonatal diagnosed with GDM.
outcomes continuously increased as a function An improvement of sensitivity from 84.8% for a
of maternal glycemia at 24-28 weeks, even within threshold of 140 mg/dL to 97.4% for a threshold of
ranges previously considered normal for pregnancy. 132 mg/dL has been demonstrated, with an increased
These results have led to careful reconsideration of screen positive rate and the performance of diagnostic
the diagnostic criteria for GDM and nowadays the OGTTs rising from 28.7% to 35.0%. Thus, if women
International Association of Diabetes and Pregnancy with a GCT between 130 and 139 mg/dL remain at
Study Groups (IADPSG), an international consensus risk for due to hyperglycemia or undiagnosed GDM,
group with representatives from multiple obstetrical then a threshold of 140 mg/dL may not adequately
and diabetes organizations, including ADA, has capture those at risk. Indeed, our study shows that
recommended new diagnostic criteria for GDM (34). women with a GCT between 130 and 139 mg/dL are
According to the statement of IADPSG, 75 g OGTT at risk for GDM. Of note, the percentage of women
at 24-28 weeks of gestation was recommended with in our cohort whose GCT values were 140 mg/dL or
cut-off values of 5.1 mmol/L (≥92 mg/dL) for fasting higher was 28.7%, and the percentage with plasma
plasma glucose (FPG), 10.0 mmol/L (≥180 mg/ glucose of 132 mg/dL or higher was 35.0%, which
were higher than those reported by Coustan et al.
dL) for 1 h, and 8.5 mmol/L (≥153 mg/dL) for 2 h
in 1998 (37). The reason for the higher rate may be
plasma glucose. Because only one abnormal value is
ethnic and environmental differences and increased
sufficient to make the diagnosis, these new criteria
obesity in the Turkish population.
will significantly increase the prevalence of GDM.
In addition, there are few data regarding therapeutic In conclusion, we recommend GCT as an
interventions in women who will now be diagnosed international screening method. It is also suitable for
with GDM based on only one blood glucose value Turkish women. The place of residence as well as race
above the specified cut-off points but fall in the need be taken into consideration to establish the best
normal category according to the older criterion that cut-off level of GCT, since ethnic and environmental
factors may contribute to the occurrence of
needs at least 2 abnormal values for diagnosis.
GDM. Furthermore, with the C&C criteria, the
A few months ago, the 6th International highest sensitivity is achieved by using the glucose
Symposium on Diabetes and Pregnancy was held in challenge test threshold of 130 mg/dL in the Turkish
Salzburg, Austria. It was stated in the symposium that population. Because of the fact that failure to identify
the risk of adverse pregnancy outcomes in women and treat GDM may result in an increase in perinatal
with fasting plasma glucose (FPG) near to the cut- and maternal morbidity and mortality, in addition
off value (FPG < 92) is not increased, indicating to long-term complications, we think that a glucose
that the new criteria may lead to overdiagnosis. challenge test threshold of 130 mg/dL should be
Similarly, there was a poor correlation between FPG considered a positive screening result.
529Screening for gestational diabetes in Turkish women
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